Improving mental health through fostering healthy lifestyles in young people: one of the targets in the <scp>WPA</scp> Action Plan 2023‐2026
Authors: Danuta Wasserman, Celso Arango, Andrea Fiorillo, Saul Levin, Andrew Peters, Prasad Rao, Thelma Sanchez‐Villanueva, Aida Sylla
Journal: World Psychiatry (2023)

The life-course approach to health shows how early exposure to physical, environmental and psychosocial factors shapes future health and mental health. In particular, when this exposure occurs during critical life phases such as adolescence, it may cause shifts in health trajectories that become difficult to restore1, 2. Future health and mental health patterns are established during youth. More than 80% of tobacco smokers start smoking between ages 14 and 25. In many countries, alcohol use starts before 15 years of age, with 13.6% of 15-19-year-olds reporting heavy episodic drinking. Heavy alcohol use during late adolescence tends to persist in adulthood and is associated with alcohol dependence. The onset of cannabis use often occurs around 18-19 years of age, and initiation at a younger age increases the risk to develop cannabis and other substance use disorders. Similarly, the peak age of onset of mental disorders is around 14 years3. Health and mental health are strictly interconnected. In young people, engaging in health risk behaviors – such as smoking, excessive alcohol consumption, risky sexual behaviors, as well as reduced sleep, sedentariness, and high media use – is significantly associated with high depression and anxiety symptoms as well as with suicidal ideation4. The WPA Planning Committee 2020-2023 strongly believes that there is "no health without mental health". We are convinced that we cannot help people achieve good mental health without improving their general health. Consequently, we wish to increase the contribution of the WPA to the achievement of the third United Nations (UN) Sustainable Development Goal: "Ensure healthy lives and promote well-being for all at all ages". Early health promotion and prevention are important to achieve good results during the life course. We recognize that physical and mental health go hand in hand, and are both influenced by early life experiences. Thus, focusing efforts and resources on prevention becomes the most effective way to reduce the burden of mental disorders3. More than 248 million adolescents live with a mental disorder, corresponding to 14% of the global adolescent population. Anxiety disorders (4.31%), depressive disorders (2.61%), and attention-deficit/hyperactivity disorder (2.39%) are the most common diagnoses in this age group. Indeed, self-harm, depressive disorders and anxiety disorders are respectively the third, fourth and sixth leading causes of disability among youth, while suicide represents the fourth leading cause of death in 15-19-year-olds5. The UN International Children's Emergency Fund (UNICEF) estimated that the annual loss in human capital due to children's mental health conditions is equivalent to US$ 340.2 billion, with an additional US$ 47 billion loss caused by intentional self-harm. Besides the huge burden posed by diagnosed mental disorders, around 30% of the youth population experience sub-threshold anxiety and depressive symptoms which are associated with functional impairment and suicidality. Geopolitical and ecological crises highly impact youth mental health. The COVID-19 pandemic likely doubled the prevalence of youth mental health difficulties. Globally, 1 in 4 youth experienced clinically elevated depression symptoms, and 1 in 5 experienced clinically elevated anxiety symptoms, with girls and older adolescents being the most affected6. Furthermore, when people were adjusting to the new normality related to the ending phase of the pandemic, the escalation of the Russian-Ukrainian war emerged as another source of distress. One year after the Russian invasion, the UNICEF estimated that 1.5 million Ukrainian children are at risk of depression, anxiety, post-traumatic stress disorder, and other mental health issues. Finally, natural disasters, noise and air pollution, overcrowding and poor housing conditions, migration, food insecurity, economic recession, and climate change can have major negative impacts on children and adolescents' emotions and mental health. It has been hypothesized that the risk of anxiety disorders and depression is reduced by the absence of noise and the restorative qualities of green spaces, since they promote mindfulness and interrupt rumination7. Furthermore, engaging in this and other positive leisure activities may reduce screen time and thus prevent its negative impact on mental health8. In order to decrease the burden of mental health in the youth, we need to address the problem at both the system and individual level. Evidence-based treatments for psychiatric disorders in children and adolescents do exist. Psychotherapies and pharmacotherapies, and their combination, are known to improve depressive and anxiety symptoms. Nevertheless, there are considerable gaps in the availability of mental health policies, resources and services both in low- and high-income countries. On average, countries devote globally only 2% of their health budget to mental health, and only 7.1% of mental health research expenditures are allocated to prevention. Additionally, limited mental health knowledge, perceived social stigma, and lack of trust in mental health professionals prevent young people and their parents from seeking help, further reducing access to services. In this scenario, schools become essential settings for providing mental health interventions. Thanks to the role that schools play in the life of young people, barriers to accessing services – such as time, location, perceived stigma, and lack of trust – may be overcome. For every US dollar invested in school-based interventions that address anxiety, depression and suicide, a return of US$ 21.5 over the course of 80 years is expected9. Universally delivered psychosocial interventions, especially those based on interpersonal skills training, emotional regulation, alcohol, drug and lifestyle education, can improve youth mental health and reduce risky behaviors. Randomized controlled trials showed that, compared to control groups, school-based interventions have a significant positive effect on symptoms of depression and anxiety, suicide attempts, and suicidal ideation10, 11. Interventions aimed to promote healthy lifestyles also improve youth mental well-being. Sleep is pivotal to youth mental health, cognitive functioning, and school performance. Nevertheless, up to 70% of youth report less than eight hours of sleep per night. School-based sleep education programs were found to significantly prolong weekday and weekend total sleep time and improve mood, and delayed school starting times were found to extend sleep duration and reduce daytime sleepiness12, 13. Meeting the recommended level of physical activity is also crucial for achieving good health and mental health. Interventions aimed at enhancing levels of physical activity were found to reduce depression, anxiety and stress, while promoting resilience, well-being and self-esteem in young people14. The available evidence also supports a positive association between a healthy diet and better mental health in youth, although further studies are needed. A limitation of universal youth mental health interventions is that their effects tend to fade over time. Positive mental health outcomes can be sustained only when the acquired awareness, coping strategies, lifestyle and social skills are internalized and become part of everyday life. Therefore, the WPA Action Plan 2023-2026 will be dedicated to promoting a life-course and holistic approach to improving mental health and preventing mental disorders by fostering the adoption and preservation of healthy lifestyle practices from an early age, spanning households, educational institutions, and health care facilities15. Previous WPA efforts in this area16, 17 are recognized, but the focus on fostering healthy lifestyles, complementary to existing treatments, will become an absolute priority in the new triennium. Healthy lifestyles are an excellent addition to existing treatments for psychiatric disorders. They increase self-governance, decision latitude, and self-confidence. When they are performed in a group, the sense of loneliness diminishes and belongingness increases. Educational materials in the form of booklets and videos, currently in the production phase, will be disseminated, and their effectiveness will be investigated by the WPA18. Achieving this objective necessitates a multi-stakeholder partnerships involving families, education and social services, mental health agencies, and the research community.